Dataset Information

Case report. Thrombus formation on left atrial appendage clip: surgical exclusion and anticoagulation do not obviate transesophageal echocardiography prior to cardioversion.

ABSTRACT:

Background

The cornerstone treatment for atrial fibrillation (Afib) is based on the prevention of cardioembolism with the use oral anticoagulants, which inherently increase the risk of bleeding. An alternative for these patients corresponds to left atrial appendage (LAA) exclusion/closure techniques such as Atriclip.

Cases summary

Patient 1: Seventy-two-year-old female who presented with decompensated heart failure, non ST elevation myocardial infarct, and paroxysmal Afib. She underwent coronary artery bypass graft, MAZE procedure, mitral valve repair, and Atriclip (40 mm). Recurrence of Afib postoperatively led to a precardioversion transesophageal echocardiogram (TEE) which demonstrated a LAA pouch thrombus. Patient 2: Sixty-seven-year-old male who underwent electively mitral and tricuspid valve repairs, MAZE procedure, and Atriclip (35 mm). He had recurrent atrial flutter/Afib postoperatively. He received apixaban in addition to rate control medications, and he was readmitted for precardioversion TEE which also demonstrated a LAA pouch thrombus.

Discussion

Atriclip is a stapler exclusion device via epicardial approach which has shown excellent exclusion rates in contemporary data. One of the pitfalls of this technique is the possibility of leaving a LAA remnant stump or pouch that is highly thrombogenic. The optimal timing for stopping anticoagulation and the need for precardioversion echocardiography remain uncertain.

SUBMITTER: Lo Presti S

PROVIDER: S-EPMC9206415 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ObjectivesWe demonstrate the feasibility and safety of robotics-assisted left atrial appendage clip exclusion in clinical practice.MethodsAnalysis of a single center robotics-assisted left atrial appendage clip exclusion experience using an epicardial linear clip device in patients with atrial fibrillation with high-risk of thromboembolic stroke and intolerance to oral anticoagulants.ResultsDuring the period from December 2017 to September 2020, we performed 42 robotics-assisted left atrial appendage clip exclusions in response to increased risk of bleeding in patients with atrial fibrillation and intolerance to oral anticoagulants. The average congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease score was 5.2 ± 1.6 and hypertension, abnormal liver or kidney function, stroke, bleeding, labile international normalized ratio, elderly, drugs (aspirin, other antiplatelets, or anticoagulants) score was 4.5 ± 0.9. No patients died intraoperatively or within 30 days, or due to conversion to thoracotomy, intraoperative complications, or failure to apply the clip satisfactorily. The procedure was successfully completed despite pericardial adhesions in 2 patients with prior coronary bypass grafts and 3 with postpericarditis scars. Intraoperative transesophageal echocardiography was performed in 38 out of 42 patients; satisfactory exclusion with left atrial appendage stump <5 mm was confirmed in all. Average length of stay was 3.4 ± 3 days with 12 out of 42 patients discharged within 24 hours. Oral anticoagulants were discontinued in 41 out of 42 patients and no cases of 30-day stroke, myocardial ischemia, or new arrhythmias were observed. One case of hemothorax required thoracoscopy a day later. There was no reported thromboembolic stroke or transient ischemic attack at 12 months. One case of late lacunar stroke was due to in situ small intracranial vessel thrombosis without left atrial appendage thrombus on imaging.ConclusionsRobotics-assisted left atrial appendage clip exclusion is a safe and feasible minimally invasive method for left atrial appendage management in patients with atrial fibrillation with intolerance to oral anticoagulants and increased risk of thromboembolic stroke.

Project description:Transesophageal echocardiography (TEE) is the gold standard for assessing left atrial appendage (LAA) mechanic and thrombosis (LAAT); however, TEE is a high-risk procedure for viral transmission during coronavirus disease 2019 (COVID-19) pandemic. We investigated whether deformation indices of left atrium (LA) at transthoracic echocardiography (TTE) correlate with those of LAA assessed by TEE in nonvalvular atrial fibrillation (NVAF) patients undergoing electrical cardioversion (ECV). Consecutive patients with NVAF of ≥ 48 h or unknown duration, who underwent TEE and TTE at our Institution before ECV were retrospectively investigated. Standard echo-Doppler and LA and LAA myocardial strain and strain rate parameters were analyzed. A total of 115 NVAF patients (71.3 ± 8.1 yr/o, 59.1% men) were included: LAAT was diagnosed in 25 (21.7%) patients. Compared to patients without LAAT, those with LAAT had significantly higher CHA2DS2-VASc Risk score (4.5 ± 1.4 vs. 3.5 ± 1.1, p < 0.001), and lower ejection fraction (46.0 ± 14.8 vs. 57.6 ± 8.6%, p < 0.001). In LAAT patients, global strain of LA (8.7 ± 2.6 vs. 16.3 ± 4.5%, p < 0.001) and LAA (7.0 ± 1.7 vs. 11.7 ± 2.0%, p < 0.001) was significantly reduced compared to non-LAAT patients. A close relationship between left atrial strain reservoir (LASr) and LAA-global strain was demonstrated (r = 0.81). By univariable analysis, CHA2DS2-VASc Risk Score (OR 2.01, 95%CI 1.34-3.00), NT-proBNP (OR 1.36, 95%CI 1.19-1.54), ejection fraction (OR 0.92, 95%CI 0.88-0.96), E/e' ratio (OR 2.07, 95%CI 1.51-2.85), and LASr (OR 0.39, 95%CI 0.25-0.62) were strongly associated with LAAT presence at TEE. By multivariable analysis, only LASr (OR 0.40, 95%CI 0.24-0.70) retained statistical significance. ROC curve analysis revealed that an LASr cut-off value ≤ 9.3% had 98.9% sensibility and 100% specificity to identify LAAT by TEE (AUC = 0.98). In patients with NVAF of ≥ 48 h or unknown duration, scheduled to undergo ECV, LA deformation assessment by TTE might substitute invasive measurement of LAA function by TEE, simplifying diagnostic approach and possibly contributing to reduce COVID-19 infection diffusion.